The patient who had a stroke needs to be fed. What instruction should you give to the nursing assistant who will feed the patient?

Correct Answer: A

Rationale: In this scenario, option A, which instructs the nursing assistant to position the patient sitting up in bed before feeding her, is the correct answer. This is because positioning the patient in an upright position helps prevent aspiration, a common risk for stroke patients with swallowing difficulties. By sitting the patient up, gravity assists in the safe passage of food down the esophagus. Option B, checking the patient's gag and swallowing reflexes, is important but should have been done by the healthcare provider or nurse before the feeding task. Nursing assistants should not independently assess these reflexes. Option C is incorrect as it promotes rushing through the feeding process, which can increase the risk of aspiration and compromise the patient's safety and dignity. Option D is also incorrect because suctioning between bites of food is not a standard practice and should only be done if there is a specific medical indication for it. Educationally, this question highlights the importance of proper positioning during feeding for stroke patients to prevent complications like aspiration pneumonia. It emphasizes the role of nursing assistants in following established protocols for patient safety and the importance of understanding the rationale behind each task in patient care.

Correct Answer: B

Rationale: The correct answer is B) observing for myasthenic crisis. When a patient's medication is being adjusted, especially in the case of Susan who may be on medications affecting neuromuscular transmission like those for myasthenia gravis, it is crucial to monitor for potential complications such as myasthenic crisis. This is a life-threatening condition characterized by severe muscle weakness that can lead to respiratory failure. Prioritizing the observation for signs and symptoms of myasthenic crisis ensures prompt recognition and intervention if it occurs, which is essential for patient safety and well-being. Option A) developing a therapeutic relationship, while important for overall care, is not the priority when a patient's medication is being adjusted and a potential crisis needs to be monitored for. Option C) initiating a teaching plan and Option D) instructing her family about medications are also important aspects of care but do not take precedence over the immediate safety concern of monitoring for myasthenic crisis. In an educational context, understanding the prioritization of care based on the patient's condition and potential complications is vital for healthcare providers to ensure effective and safe patient management. This question highlights the importance of critical thinking and clinical decision-making in prioritizing nursing interventions during medication adjustments and potential crisis situations in neurological system assessments.

Correct Answer: A

Rationale: In this question, the correct answer is A) hyperthermia. During spinal shock, which is a temporary loss of reflexes below the level of a spinal cord injury, the body's ability to regulate temperature, including perspiration, is disrupted. As a result, the patient is unable to sweat below the level of the injury, leading to a decreased ability to cool down the body. This can result in hyperthermia, an elevated body temperature. Option B) overhydration is incorrect because the inability to perspire does not lead to increased hydration. Option C) hypertension is incorrect as there is no direct link between the inability to perspire and increased blood pressure. Option D) autonomic dysreflexia is also incorrect as this condition occurs after spinal shock and is characterized by a sudden onset of excessively high blood pressure. In an educational context, understanding the physiological responses and complications of spinal cord injuries is crucial for healthcare providers, especially those involved in caring for patients with such injuries. Recognizing the effects of spinal shock on temperature regulation can help healthcare professionals anticipate and prevent complications such as hyperthermia in these patients. This knowledge is essential for providing safe and effective care to individuals with spinal cord injuries.

Correct Answer: C

Rationale: In the case of Mr. Jones, the most appropriate position until doctor's orders are received is lying on his right side. This position is preferred as it helps reduce pressure on the vena cava, the large vein that returns blood to the heart. By lying on the right side, Mr. Jones can optimize blood flow and cardiac output, which is crucial for patients in compromised health states. Option A, lying flat on his back, may impede blood flow through the vena cava, leading to decreased cardiac output and potential complications. Option B, lying on his left side, can compress the vena cava, also hindering blood flow. Option D, lying on his abdomen, is not suitable as it can cause respiratory distress and compromise airway patency. In an educational context, understanding the rationale behind positioning patients is crucial for nursing and medical students. It ensures safe and effective patient care by promoting optimal physiological function and preventing complications. Clinical reasoning skills are honed through understanding the implications of different positions on patient outcomes.

Correct Answer: A

Rationale: The correct answer is A) Working with modeling clay. This activity will least prepare Mr. Hall for crutch walking because it does not directly engage the muscles and coordination required for walking with crutches. Crutch walking involves upper body strength, balance, coordination, and grip strength, which are not specifically targeted by working with modeling clay. Option B) Lifting dumbbells can improve upper body strength necessary for supporting oneself while using crutches. Option C) Assembling model cars can enhance fine motor skills and hand-eye coordination, which are beneficial for using crutches effectively. Option D) Using a handgripper can strengthen grip muscles, essential for holding onto the crutches securely. In an educational context, understanding the rationale behind each answer choice helps students grasp the importance of tailored rehabilitation activities to specific functional goals. By analyzing why certain activities are more relevant than others in preparing for crutch walking, students can apply this critical thinking to real-life patient scenarios, ensuring effective and individualized interventions.